Michael J. Wheatley

Early recovery after endoscopic vs. short-incision open carpal tunnel release

&NA; Endoscopic carpal tunnel release has been claimed to offer improvement in recovery time and postoperative discomfort over open carpal tunnel release. Short‐incision open carpal tunnel release has been claimed to offer recoveries comparable with endoscopic techniques. Patients receiving carpal tunnel surgery were randomized to short‐incision open release or single‐portal endoscopic release. Preoperative and postoperative evaluation included grip and pinch strength measurements and patient completion of a questionnaire regarding symptoms and function. Thirty‐six operated hands completed evaluation, including 22 endoscopic and 14 open releases. Early grip and pinch strength after endoscopic carpal tunnel release were improved significantly over short‐incision open release (p < 0.05). Subjective evaluation indicated a trend toward improved symptoms and function with endoscopic over short‐incision open carpal tunnel release. Endoscopic carpal tunnel release provides faster recovery of strength than short‐incision open carpal tunnel release and improves early postoperative comfort and function to a small degree. Mackenzie DJ, Hainer R, Wheatley MJ. Early recovery after endoscopic vs. short‐incision open carpal tunnel release. Ann Plast Surg 2000;44:601‐604

Reduction mammaplasty: a review of managed care medical policy coverage criteria.

Background: Insurance companies evaluate the medical necessity for breast reduction surgery based on internal company medical policies, but the correlation of insurance company criteria to the scientifically established indications for reduction mammaplasty has never been studied. The authors obtained 90 insurance company medical policies for reduction mammaplasty to determine whether the criteria on which coverage determinations are made are consistent with published data regarding the indications for this procedure. Methods: The authors reviewed the medical literature on reduction mammaplasty and identified what conclusions can reasonably be drawn from this literature on the common insurance criteria used to determine medical necessity for reduction mammaplasty. Conclusions based on the medical literature regarding volume of reduction, symptom presentation, conservative therapy, obesity, presence of bra strap grooving and intertrigo, and age at time of reduction were formulated, and these conclusions were compared with the criteria of 90 different health insurance reduction mammaplasty medical policies. Results: The authors were unable to identify any medical policies that could be supported in entirety by the medical literature and many that are completely unfounded based on the medical literature. Conclusions: Insurance company medical policy requirements with respect to reduction mammaplasty are, in many cases, arbitrary and without scientific basis. Requirements for a specific volume of reduction, a minimum age, a maximum body weight, and a trial of conservative therapy are required by the majority of managed care medical policies, even though scientific support for any of these requirements is not evident in the medical literature.

The role of vascular pedicle thrombectomy in the management of compromised free tissue transfers

Microvascular free tissue transfer has become a very reliable reconstructive technique. Occasionally, flap compromise will occur and will require urgent flap reexploration. In the setting of complete thrombosis of pedicle vessels, thrombectomy using Fogarty #2 and #3 catheters can be effective in restoring vascular patency. Seven flaps with arterial, venous, or both vessel thrombosis were managed with thrombectomy at the time of reexploration and anastomotic revision. Six of the flaps were completely salvaged and the seventh was partially salvaged. Promptness in reexploration increased the likelihood of complete flap salvage. The use of postthrombectomy heparinization was associated with a 50% complication rate in this series. Thrombectomy of free flap vessels can be safely performed and is associated with a low incidence of rethrombosis.

Recurrent carpal tunnel syndrome following endoscopic carpal tunnel release : A preliminary report

Persistent or recurrent symptoms following endoscopic carpal tunnel release have been reported in 0.5% to 3% of patients undergoing this procedure. Unfortunately, preoperative risk factors for this complication have not been defined. We reviewed the records of 126 consecutive patients who underwent Agee single-portal endoscopic carpal tunnel release between June 1994 and March 1997. Five patients and six hands required subsequent open carpal tunnel release for persistent or recurrent carpal tunnel syndrome. Fulminant synovitis was identified during open carpal tunnel release in all reexplored patients, and four of the six hands were cured with open release and synovectomy. No recurrences were identified in the group of patients who presented with unilateral carpal tunnel syndrome. The presence of bilateral carpal tunnel syndrome may be a risk factor for persistent or recurrent carpal tunnel syndrome following endoscopic carpal tunnel release.

Muscle hernias of the leg: A case report and comprehensive review of the literature.

A case involving a retired, elderly male war veteran with a symptomatic peroneus brevis muscle hernia causing superficial peroneal nerve compression with chosen surgical management is presented. Symptomatic muscle hernias of the extremities occur most commonly in the leg and are a rare cause of chronic leg pain. Historically, treating military surgeons pioneered the early documentation of leg hernias observed in active military recruits. A focal fascial defect can cause a muscle to herniate, forming a variable palpable subcutaneous mass, and causing pain and potentially neuropathic symptoms with nerve involvement. While the true incidence is not known, the etiology has been classified as secondary to a congenital (or constitutional) fascial weakness, or acquired fascial defect, usually secondary to direct or indirect trauma. The highest occurrence is believed to be in young, physically active males. Involvement of the tibialis anterior is most common, although other muscles have been reported. Dynamic ultrasonography or magnetic resonance imaging is often used to confirm diagnosis and guide treatment. Most symptomatic cases respond successfully to conservative treatment, with surgery reserved for refractory cases. A variety of surgical techniques have been described, ranging from fasciotomy to anatomical repair of the fascial defect, with no consensus on optimal treatment. Clinicians must remember to consider muscle hernias in their repertoire of differential diagnoses for chronic leg pain or neuropathy. A comprehensive review of muscle hernias of the leg is presented to highlight their history, occurrence, presentation, diagnosis and treatment.

Secondary fractures of Le Fort I osteotomy.

Purpose To report the ophthalmic complications of Le Fort I osteotomy for the correction of dentofacial deformities and to determine the maximal compressive loads applied during pterygomaxillary separation in a cadaver model. Methods Two cases of ophthalmic complications arising after Le Fort I osteotomy are reported. Le Fort I osteotomy was performed on five cadavers. The maximal compressive load applied during pterygomaxillary separation was recorded with a 10 kN (3,000 lbf) load cell of a MTS Mini-Bionix servohydraulic machine (MTS, Eden Prairie, MN, U.S.A.). A paired t test was used to compare forces applied to the right and left sides. Computed tomography scans of each specimen were obtained after Le Fort I osteotomy to document secondary fractures. The skulls were subsequently stained with 1% fuschin red to highlight secondary fractures. Results Maximum compressive loads during pterygomaxillary separation ranged from 22 N (5.0 lbf) to 162 N (36.5 lbf), with an average of 106 N (23.8 lbf) (SD 47.6 N [10.7 lbf]). Forces applied on the first operative side were significantly greater than forces applied on the second operative side (p = 0.0034). Secondary fractures were found in three specimens by computed tomography and in two specimens by 1% fuschin red. All secondary fractures occurred on the second operative side. Conclusion Secondary fractures in the Le Fort I osteotomy procedures occurred on the side opposite the greater maximal compressive load and on the second operative side.

Successful hand revascularization with urokinase following a crush injury.

Acute hand ischemia is a medical emergency requiring immediate treatment. We report a case of acute hand ischemia due to a crush injury of the wrist. Management with urokinase was successful in reestablishing flow to the ulnar artery and the digital vessels. In the setting of acute trauma with extensive thrombosis of the vessels of the hand, thrombolytic therapy may offer a better treatment option than surgical exploration with bypass grafting.

Use of the radial forearm free tissue flap to treat persistent stricture after esophagogastrectomy

BACKGROUND Persistent stricturing or anastomotic leakage at the cervical esophagogastric anastomosis can be a troublesome complication of gastric pull-up procedures. When the stricture is the result of ischemia of the stomach, the strictures are long and often not responsive to dilatation and require large operations such as jejunal interposition or replacement with colonic pull-up. In this report we describe the use of a radial forearm flap to patch strictures. METHODS The radial forearm flap is a fascia cutaneous flap taken from the forearm and based on the radial artery and its venae comitantes. The advantages of this flap are that it is thin and pliable, conforms easily, has excellent reliability due to the size of the feeding vessels, and has a relatively long pedicle. The vascular anastomosis can be made to several arteries and veins within the neck. The epithelial component can be made in sizes up to 10 by 20 cm. RESULTS We have used the radial forearm flap to patch strictures in 6 patients with persistent complex strictures in the cervical region after esophagectomy. Results were excellent in 4 patients (able to eat liquids and solids without problems) and good in 1 patient (liquids okay, some problem with solids), and 1 patient died postoperatively. Follow-up is 4 months to 7 years. CONCLUSIONS The radial forearm flap is an excellent option for handling persistent stricture after esophagogastrectomy. In many instances, this flap can be used in lieu of a jejunal interposition flap and obviates a laparotomy to harvest jejunum. The flap fits easily into the neck and conforms to the space.

Closed traumatic rupture of the thenar muscles from the origin: a case report and review of the literature.

Closed traumatic rupture of the thenar muscles is an unusual and rare injury. Traumatic musculotendinous injuries in the hand and wrist occur primarily from penetrating trauma. Only 2 such cases were identified in medical literature. We report a case of closed traumatic rupture of the thenar muscles in an otherwise healthy 33-year-old female nurse who sustained a hyperabduction injury of her right thumb and wrist during a daily occupational routine, resulting in complete avulsion of the right abductor pollicis brevis and opponens pollicis from their origins. After declining initial surgical management, the patient subsequently returned 6 months later reporting continued pain, paresthesias, and thenar deformation, and requested surgical intervention. On examination, she continued to exhibit weakness of thumb abduction and mild weakness with opposition. She was again offered an open carpal tunnel release with exploration of the thenar eminence and possible tendon transfer, although she adamantly refused any tendon transfer. An open right carpal tunnel release was performed with exploration and direct muscle repair through a lateral thenar incision. Primary muscular reattachment was accomplished by suturing the abductor pollicis brevis and opponens pollicis to the flexor retinaculum and the trapezium. Functional results 15 months after surgery were satisfactory with improvements in abduction and opposition of the thumb and restoration of the thenar contour. The chosen surgical technique for repair resulted in good functional outcome, while avoiding the need for tendon transfer.